Intolerance to Enteral Nutrition

OVERVIEW

  • Intolerance to enteral nutrition is characterised by excessive aspirates (>500mL q6h),vomiting, abdominal distension, constipation or diarrhoea

CAUSES

Patient

  • GORD
  • hiatus hernia
  • gastroparesis/ileus
  • pseudo-obstruction
  • retroperitoneal haematoma/oedema
  • bowel injury
  • bowel ischaemia
  • shock
  • sepsis
  • pancreatitis
  • bowel obstruction
  • hyperglycemia
  • hypoxia / ischemia
  • trauma
  • burns

Mechanical

  • NGT not placed in stomach
  • kinking
  • blockage

Drugs

  • opioids
  • sedation
  • no prokinetics
  • hyperosmolar formulas

ASSESSMENT

History

  • sedation/analgesia: hold?
  • history of symptoms
  • discussion with surgeon
  • search for sepsis, pancreatitis, MI, GI pathology, cause of shock

Examination

  • to find above pathologies

Investigations

  • AXR
  • CXR (erect)
  • CT abdomen

MANAGEMENT

General approach

  • rule out bowel obstruction
  • minimize drugs causing gastroparesis or ileus
  • correct electrolytes
  • start at low volumes with steady increases until goal rate achieved
  • prokinetics
  • consider NJ feeding
  • TPN

Approach to gastric residual volumes >500mL q6h


References and Links

LITFL

Journal articles

  • Deane A, Chapman MJ, Fraser RJ, Bryant LK, Burgstad C, Nguyen NQ. Mechanisms underlying feed intolerance in the critically ill: implications for treatment. World J Gastroenterol. 2007 Aug 7;13(29):3909-17. PMID: 17663503.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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